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Digestive adaptation: A new surgical proposal to treat obesity
ORIGINAL ARTICLE
Digestive adaptation: A new surgical proposal to treat obesity
Adaptação digestiva: Uma nova proposta cirúrgica para tratar a obesidade com base em
Sérgio Santoro 1, Manoel Carlos Prieto Velhote 2, Carlos Eduardo Malzoni 3, Alexandre Sérgio Gracia Mechenas 4,
ABSTRACT
omentectomia e enterectomia que mantém os primeiros 150 cm
Objective: To report on a new surgical technique to treat obesity -
de jejuno e os últimos 150 cm de íleo. Os três primeiros pacientes
Digestive Adaptation - and to present its preliminary results.
obesos tratados por esta técnica são apresentados. Resultados:Method: The technique includes a vertical (sleeve) gastrectomy,
Com seguimento mínimo de seis meses, todos os pacientes estão
omentectomy and enterectomy maintaining the initial 150-cm-
livres de sintomas, referem saciedade mais precocemente e já
portion of the jejunum and the final 150-cm-portion of the ileum.
estão com IMC menor que 31 Kg/m2. Conclusões: Este procedi-
The three first obese patients operated on are described. Results:
mento evita criar subestenoses, colocar próteses, excluir
With a minimum follow-up of 6 months, all patients refer early
segmentos digestivos do trânsito de nutrientes, gerar malabsorção
satiety, are free of symptoms and have a BMI <31 Kg/m2.
e fundamentalmente, evita prejudicar funções digestivas. O
Conclusions: This procedure does not use prostheses and does
procedimento visa gerar uma restrição moderada, o que colabora
not cause exclusion of gastrointestinal segments. It does not
para a saciedade precoce por distensão gástrica com menores
create subocclusions neither malabsorption nor blind endoscopic
volumes e visa também modificar as circunstâncias neuroendó-
areas and above all, it causes no harm to important digestive
crinas, retardando o esvaziamento gástrico, e gerando saciedade
functions. Conversely, it aims at moderate restriction with early
precoce e prolongada, paralelamente a mudanças positivas no
satiety by distension, and at interfering in the neuroendocrine
perfil metabólico. Baseado em dados fisiológicos recentemente
profile, resulting in slow gastric emptying, early and prolonged
descobertos, o procedimento pretende diminuir a produção de
satiety, as well as positive changes in the metabolic profile. Based
grelina, do inibidor da ativação do plasminogênio 1 (PAI-1), da
on recent physiological data, the procedure aims at decreasing
resistina e finalmente promover a secreção mais efetiva do
the production of ghrelin, plasminogen activator inhibitor-1 (PAI-1)
glucagon-like peptide 1 (GLP-1). O paciente operado não necessita
and resistin, and at raising the levels of glucagon-like peptide-1
de suporte nutricional nem de uso crônico de medicações por
(GLP-1). The patients operated on do not need nutritional support
causa do procedimento, que é simples e fácil de ser realizado.
or to take drugs because of the procedure, which is easy and safeto perform.DESCRITORES: Obesidade mórbida/cirurgia; Inibidor 1 de ativadorde plasminogênio; Omento/fisiologia; Tecido adiposo/fisiopatologia;Keywords: Obesity, morbid/surgery; Plasminogen activator
Gastrectomia/métodos; Hormônios peptídicos; Citocinas/fisiologia
inhibitor 1; Omentum/physiology; Adipose tissue/physiopathology;Gastrectomy/methods, Peptide hormones; Citokines/physiology
INTRODUCTIONIn the 20th century, we observed a great increase in the
incidence of obesity, hypertension, diabetes, hypertrigly-
Objetivo: Esta é a comunicação preliminar, com resultados iniciais,
ceridemia, hypercholesterolemia, and other conditions
de uma nova técnica cirúrgica para tratar a obesidade: Adaptação
associated with changes in human diet. Nutritional
Digestiva. Método: A técnica inclui uma gastrectomia vertical, a
education and medical treatment have failed to avoid
* Study carried out at Hospital da Polícia Militar do Estado de São Paulo.1 Master’s degree in Medicine by the Medical School of Universidade of São Paulo (FMUSP), Fellow of Colégio Brasileiro de Cirurgia Digestiva.2 Ph.D. in Medicine by FMUSP, Assistant Professor of the Discipline of Pediatric Surgery of FMUSP.3 Master’s degree in Medicine by FMUSP, Full member of Colégio Brasileiro de Cirurgiões4 Fellow of Colégio Brasileiro de Cirurgia Digestiva, Fellow of Sociedade Brasileira de Cirurgia Lapaoscópica5 Ph.D. in Medicine by the Department of Surgery of FMUSP, Assistant Professor of Digestive Surgery of FMUSP.6 Clinician, Researcher in Rheumatology-Immunology, Ph.D. by Boston University, Post-doctorate by USP.
Corresponding author: Sérgio Santoro - R. São Paulo Antigo, 500 - apto. 111 SD, São Paulo - SP 05684-010 BRAZIL - e-mail: ssantoro@ajato.com.brReceived on September 4, 2003 – Accepted on November 14, 2003
Santoro S, Velhote MCP, Malzoni CE, Mechenas ASG, Strassmann V, Scheinberg M
obesity, and many surgical techniques to treat extreme
increase food intake and decrease use of fat(11-13).
obesity have been presented although none has been
Ghrelin production drops after a meal and later on, it
satisfactory. Current surgical treatment causes “another
increases - this has been demonstrated as taking part
disease” to counterbalance obesity. Some techniques
in the mechanism of hunger(14). High ghrelin levels are
result in malabsorption, yet unspecific, leading to loss
not a common cause of obesity since it was demonstrated
of non-caloric nutrients, such as calcium, iron, folic
that obese individuals present low levels of this
acid, etc., and to diarrhea(1). Some procedures pose
hormone. However in case of significant weight loss,
obstacles to ingestion of food, and others use prosthesis
the levels of ghrelin raise, resulting in hunger and,
that may cause subocclusions(2), and consequently,
probably, contributing in gaining weight again(15).
dysphagia, vomiting, stasis esophagitis, etc. Many current
PAI-1: Plasminogen activator inhibitor 1 (PAI-1) is
procedures involve exclusion of digestive system
the primary physiological inhibitor of plasminogen
segments, which causes atrophy of mucosa with bacterial
activation and has procoagulation activity. Circulating
proliferation; this, in turn, leads to intense flatulence
PAI-1 levels are elevated in patients with coronary heart
and bacterial translocation to the portal system, which
disease and play an important role in the development
may be related to hepatic fibrosis(3). Additionally,
of arterial thrombosis by decreasing fibrin degradation(16) .
exclusion of segments hinders endoscopy.
PAI-1 is produced by visceral fat tissue, mainly the
We searched new surgical alternatives, which could be
omentum and mesenteric fat(16-18). Procedures causing
easy to perform, require no exclusion of any segment,
decrease in PAI-1 levels have already been demonstrated
prevent endoscopic blind areas, avoid strangling prosthesis
as improving metabolic profile and reducing cardiovascular
and cause no subocclusions. Moreover, the technique
should avoid malabsorption and above all, not harm
Resistin: It is clear today that adipose tissue is an
important digestive functions. We rather searched
endocrine gland and it produces many substances that
procedures that could positively interfere with the
could act like hormones, such as leptin, interleukin-6,
neuroendocrine control of hunger and satiety.
adiponectin (also called ACRP30 and adipoQ),
Physiological Background
angiotensin II and resistin. Resistin acts on skeletal
GLP-1: Glucagon-like peptide 1 (GLP-1) is a
muscle myocytes, hepatocytes, and adipocytes, reducing
hormone released by the enteroendocrine L-cells of
their sensitivity to insulin; thus, it is related to
the gut in response to food ingestion. GLP-1 increases
diabetes(21-22). Abdominal fat is the main source of
both insulin secretion and insulin gene expression and
growth of pancreatic beta-cells(4-6). GLP-1 is secreted
Visceral obesity: Abdominal fat tissue was clearly
mainly by the distal intestine and the nutrients that
related to the so-called plurimetabolic syndrome. The
reach this point are a major stimulus to release this
waist/hip ratio has been used to quantify cardiovascular
risk and many epidemiological studies have indicated
GLP-1 is a potent agent that could improve or even
its relation with high blood pressure, hypertriglyceridemia,
cure type II diabetes(4,8). When obese diabetic patients
insulin resistance and arterial thrombosis. Visceral fat
are submitted to biliopancreatic diversion (Scopinaro
is insulin-resistant and therefore releases free fatty acids
Technique)(9), the ileogastric anastomosis provides
(FFA) to the portal system. It is believed that insulin
nutrients straight into the ileum and just after the
resistance of the liver derives from a relative increase
operation, and diabetes is markedly improved or cured
in delivery of FFA from the omental fat depot to the
before patients lose any significant weight. Efficient
liver (via portal vein)(24). Many extreme obese patients
production of GLP-1 is thought to cause this major
have quite good metabolic profile because they have
mostly subcutaneous fat. Except for orthopedic and
GLP-1 also has other important actions. It inhibits
respiratory complications, as well as reflux, most metabolic
gastric emptying(7) and crosses the blood-brain barrier
complications of obesity are related to visceral fat.
causing satiety(4,10). In sum, after a big meal, when
Evolutionary Background
nutrients reach the distal intestine, GLP-1 is produced,
Primitive diet was raw, full of poorly digestible fiber
increasing the release of insulin and delaying gastric
and very hypocaloric. The stomachs had to be big
emptying and causing central satiety.
enough to keep an amount of food and handle long
Ghrelin: It is a 28-amino peptide, predominantly
fasting periods. Hence, the volume of food ingested
produced by the stomach and it has intense growth
had to be expressive. The intestines had to be very long
hormone (GH) releasing activity. Moreover, it
in order to take and process more food and to be
stimulates gastric acid secretion, and can induce excess
efficient and not loose nutrients. However, the human
adipose tissue by activating a central mechanism to
diet has deeply changed in few centuries. Fire control
Digestive adaptation: A new surgical proposal to treat obesity
made food more digestible. Agriculture gave us some
a midgut enterectomy that leaves 150 cm of proximal
abundance and increased the amount of carbohydrates.
small bowel and 150 cm of distal small bowel, totaling
Refined sugar may be given to us in considerable
3 meters of small bowel, which is still considered a
amounts, whereas nature could give us just minimal
portions. Saturated fat and industrialized food made
The Research Ethics Committee of Hospital da
the picture even worse. The development of electricity
Polícia Militar do Estado de São Paulo approved the
has allowed us to eat also at night. Marketing,
protocol. A detailed informed consent was signed by
restaurants, cookies, and the other goodies of
patients, and it stated weight loss could not be predicted
civilization have represented a very quick change that
our digestive system and our eating instincts could not
Modern diet is hypercaloric, poor in fiber and easy
to absorb. After a meal with these characteristics,
Technique: the procedure may be performed either
absorption occurs in the proximal portions of the bowel,
through a supraumbilical midline incision or laparoscopy.
resulting in a peak of nutrient absorption. Distal bowel
The open technique is described here. The first step is
tends to absorb less nutrients, and this reduces
to release the great omentum from the colon. The
production of GLP-1. Indeed, it was noticed that
gastric fundus is released by cutting the short gastric
diabetic(25) and obese people(26) have reduced postprandial
vessels with a harmonic scalpel. Later, the gastroepiploic
arcade is interrupted at 6 cm proximal to the pylorus.
It has also been shown that obese individuals tend
Gastroepiploic vessels will remain intact in the antrum.
to have longer small bowel than slim patients, and this
A 12-mm Fouchet tube is passed through the esophagus
is not related to height but to weight(27). This fact
until the duodenum by the lesser curvature. A linear
probably contributes to smaller amounts of nutrients
cutting stapler is used in order to resect the gastric
reaching the distal bowel, implying in less signaling of
fundus and most of the gastric body, leaving a gastric
tube of 3 to 4 cm of diameter in the lesser curvature
Nature now performs what it does best - selection.
(figure 1). Gastric specimen and the great omentum
Individuals with strong eating instincts are being killed
by lack of adaptation of their digestive system and its
A protective continuous seromuscular polypropylene
suture is performed over the gastric stapling line. The
A new surgical proposal to treat obesity
procedure is completed with an enterectomy that
We have been searching a manner to adapt the
removes the midgut, at 150 cm away from Treitz angle
digestive system and eating instincts to abundance,without causing damage to important digestivefunctions, like those performed by the stomach, pylorus,
duodenum, ileum and colon. The duodenum and theproximal intestine have functions different from thedistal gut. Some current techniques to treat obesity
resect or exclude the pylorus (Scopinaro´s biliopancreaticbypass(9), Fobi(28) or Capella(29) Roux-en-Y gastric bypass).In biliopancreatic bypass, using Scopinaro´s technique
or the Duodenal Switch technique(30), the entire proximalintestine is excluded and the procedure may causeunspecific malabsorption that leads to nutritional
deficiencies(1). In gastric bypass, most of the stomach isexcluded. Other techniques involve no exclusion but maycause subocclusion, such as gastric banding(2).
In our point of view, the several digestive functions
are essential, even to obese patients. However, we knowthat the gastric capacity is bigger than what modern
diet requires(31). Even the intestines are too long tomodern diet(32). Therefore, we propose a vertical gastricresection (similar to the extensively used “Duodenal
Switch” technique)(30,33) associated to omentectomy and
Figure 1. Diagram of partial gastric resection
Santoro S, Velhote MCP, Malzoni CE, Mechenas ASG, Strassmann V, Scheinberg M
Patient 2: RJSB, male, 40 years old, weight=143 kg
(315 pounds), height=182 cm (6ft), BMI=43.1 kg/m2,total cholesterol=247 mg/dl, triglycerides=295 mg/dl.The patient had been on clinical treatment for ten years,
and was taking Fenproporex. He complained of pain inthe knees and low back pain, and was submitted to surgeryin January 2003. In August 2003, he weighed 100 kg
(220 pounds), BMI=30.1 kg/m2, cholesterol=197 mg/dl;triglycerides=102 mg/dl. The patient was still loosingwhen this article was submitted to publication.Patient 3: WVBG, male, 44 years old, weight=123 kg
(271 pounds), height=178 cm (5ft10), BMI=38.6 kg/m2,total cholesterol=247 mg/dl, triglycerides= 295 mg/dl.
The patient had been on clinical treatment for tenyears, and had recently been in use of Orlistat,
Figure 2. Specimen of gastroepiploic resection
Fenproporex and amphetamine. He complained of pain
in the knees and low back pain. The patient wasoperated in February 2003. On the 23rd postoperativeday, he returned to hospital due to an abscess that was
drained. In August 2003, he weighed 99 kg (218.2pounds), BMI=31.2 kg/m2, cholesterol=142 mg/dl;triglycerides= 67 mg/dl.
All patients received cefazolin for 24 hours as
prophylaxis and were discharged on the thirdpostoperative day. They were oriented to take only
liquids, a maximum volume of 150 ml each time, duringone week; later they were allowed to eat solid food.They were recommended to start meals with a portion
of salad; fruits, vegetables and fish and chicken werealso prescribed. No patient had diarrhea, and two ofthem had mild obstipation for eating less. All patients
referred early satiety, had no symptoms and were verysatisfied.Figure 3. Specimen of enterectomy. Small bowel of 150 cm in length (patient MZF)
and at 150 cm proximal to the ileocecal valve, with its
Discussion
mesentery (figure 3). And end-to-end (entero-enteral)
The procedure has many advantages and we believe it
could adapt the digestive system to modern diet. Since
First patients and results: We report the first three
current foods are much more caloric than primitive
patients submitted to surgery and their follow-up of at
diet, the gastric capacity is reduced by 1 to 1.8 liters.
However, there is no subocclusion, no stenosis and no
Patient 1: MZF, female, 39 years old, weight=104 kg
use of prosthesis. The stomach is proportionally
(229,27 pounds), height =169 cm (5ft7), BMI: 36.4 kg/m2,
reduced, but keeping its general structure (cardia, body,
total cholesterol=210 mg/dl, triglycerides=200 mg/dl.
antrum and pylorus) and innervation by the lesser
She had been under clinical treatment for ten years.
curvature is intact. Early satiety by gastric distension
When surgery was indicated she was taking Orlistat,
tends to occur. When significant weight loss occurs,
and had used sibutramine and others drugs before. She
no raise in ghrelin production is expected since its major
could not loose any weight and complained of pain
related to disk herniation. The patient was operated
The enterectomy presented does not aim at causing
in October 2002. In August 2003, her weight was 69 kg
malabsorption. There is no report of enteric insufficiency
(152 pounds), BMI=24.1 kg/m2; cholesterol=174 mg/dl,
with 300 cm of a proportional bowel (with duodenum,
triglycerides=161 mg/dl. She used no medicine and back
jejunum, ileum, ileocecal valve and colon). In fact, some
normal people have just three meters of small bowel
Digestive adaptation: A new surgical proposal to treat obesity
(in humans, the small bowel length ranges from 3 to 8
surgeries that are physiologically aggressive. The
technique reported may be a physiologically acceptable
The intention of this procedure is to create a
procedure to treat extreme obesity. It could also be
proportionally smaller intestine that is still normal and
used to prevent extreme obesity in cases it is eminent
takes less contents; moreover, it takes nutrients to the
and patients already have associated diseases.
ileum, resulting in a more effective secretion of GLP-
This is the first surgical procedure that does not
1, which, in turn, reduces gastric emptying speed,
aim at curing an affected or deficient organ, but it
improves insulin secretion and promotes central satiety.
intends to adapt a system to modern circumstances in
Triglycerides and cholesterol levels are usually reduced
cases nutritional and medical treatment failed. In fact,
this is an evolutionary and adaptative surgery that
When enterectomy is performed, the mesentery is
would not be necessary if we had not changed our
excised and visceral fat is removed. Omentectomy
primitive diet. It might become a very important
promotes additional resection of visceral fat(17) and
procedure since it can early prevent the development
reduction of a source of PAI-1(22), reducing the risk of
of obesity, hypertriglyceridemia, hypercholesterolemia,
arterial thrombosis. It provides a reduction in the source
type II diabetes, hypertension, arterial thrombosis and
of resistin and free fat acids to the portal vein. Both
other typical conditions of modern life.
events are thought to reduce hyperinsulinism andinsulin resistance (21,24). As the specimens removed arebulky and the intraabdominal pressure (IAP) is
CONCLUSION
reduced. High IAP is related to respiratory and
The procedure presented is the association of three
well-known techniques: vertical gastrectomy, omentectomy
These preliminary results are very encouraging since
and enterectomy. All are very simple and safe. Together,
patients achieved weight loss as expected and presented
they produce a proportionally reduced digestive
neither subocclusions nor malabsorption. We should
system, however not changing its general structure as
evaluate the drop in ghrelin, resistin, PAI-1 levels and
observed in other obesity surgery techniques. No
early raise in GLP-1 levels. Besides the benefits of
stenosis, subocclusions, excluded segments, malabsorption,
weight loss, we observed the expected fall in cholesterol
blind endoscopic areas were created, and no prosthesis
and triglycerides levels. However, improvement of
was used. Above all, no harm was caused to important
metabolic profile must be assessed in a larger sample
digestive functions. The patient submitted to surgery
need no nutritional support or chronic use of drugs
Furthermore, very obese patients may not loose the
due to the procedure. The preliminary results are very
amount of weight required with this technique for it is
not aggressive to digestive functions. However, mosttechniques previously mentioned may still be used after
ACKNOWLEDGEMENTS
The current surgical procedures for obesity are so
We would like to thank U.S. Surgical for donating the
aggressive that may not be recommended to patients
disposable surgical equipment used in the procedures
who are not extremely obese. Hence, when these
performed at Hospital da Polícia Militar de São Paulo.
procedures are performed the patients already presentdamaged arteries and joints, and suffer from the
consequences of diabetes, hypertension, dyslipidemia,gastroesophageal reflux and other conditions associated
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EFFECT OF DEWORMING WITH IVOMEC POUR-ON PERFORMANCE OF GRAZING STOCKER CATTLE Story in Brief One hundred twelve healthy stocker steers averaging 533 lb and grazingsummer forages were used to evaluate the effect of ivermectin on weight gain. Treatment groups consisted of one or two treatments with ivermectin and acontrol group receiving none. Cattle receiving treatment with ivermectin